Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RH0002X | Hospice and Palliative Medicine | 10277 | MS |
Y | 207RH0003X | Hematology & Oncology | 10277 | MS |
NPI | 1205831666 |
---|---|
Provider Name | Bobby L Graham JR. |
First Address | Jackson, MS 39202-2002 |
Second Address | Jackson, MS 39216-4121 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2005 |
Last Update Date | 27/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00115226 | (05) | MS |
1966452 | (05) | LA |
4225962 | AETNA HEALTHCARE (01) | |
B29977 | (02) |